Identifying Effective Approaches to Translate Knowledge of
Health Equity to Health System Decision Makers,
Policy Makers, and Policy Analysts
Christine Boyes, MPA candidate
School of Public Administration
University of Victoria
October 23, 2014
Client: Karen Weir, Program Lead for the Canadian Population Health Initiative
Canadian Institute for Health Information
Supervisor: Dr. Kim Speers
School of Public Administration, University of Victoria
Second Reader: Dr. Rebecca Warburton
School of Public Administration, University of Victoria
Chair: Dr. Thea Vakil
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CKNOWLEDGEMENTS
I would like to acknowledge and thank Karen Weir MHSM, Canadian Population Health Initiative program lead and Sara Allin, MSc, PhD, senior researcher for the Canadian Population Health Initiative, for their support and guidance throughout the entire research and review process of this project. I would also like to acknowledge the ongoing support from the senior management of the Canadian Population Health Initiative. I would also like to acknowledge the support of my academic supervisor Dr. Kim Speers for providing useful insight and guidance throughout the proposal and review process.
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UMMARY
INTRODUCTION
The purpose of the project is to identify effective approaches of moving knowledge of health equity into action in order for the Canadian Population Health Initiative (CPHI) to strengthen their
knowledge translation (KT) activities. The term KT is a term that is used to describe the movement of research (or other knowledge) to the appropriate end-users so that it can be applied in their respective work settings. It is a catchall term that is meant to encapsulate the various actions involved in the process of taking research or information and communicating it to relevant stakeholders. The process of KT is meant to facilitate the use of evidence and different types of knowledge in various health system contexts (policy making, clinical settings etc.). Activities related to KT are actions taken by an organization or branch to further expand the reach of their products to a greater number of stakeholders and increase the stakeholder’s knowledge of how to apply the knowledge. For CPHI, these activities fall into three main categories: knowledge transfer (the creation of products and tools), knowledge exchange (collaborative initiatives), and knowledge uptake (impact evaluations).
The CPHI branch is a part of the organization the Canadian Institute for Health Information (CIHI). The CPHI branch produces resources to improve the ability of health system decision makers, policy makers, and policy analysts to act on population health and reduce health inequalities. Their
mission is to “support Canadian policy makers and health system managers in their efforts to improve population health and reduce health inequalities through research and analysis, evidence synthesis and performance measurement” (CPHI [a], 2012, p.1). In their 2012-2017 strategic plan, the branch adopted a strategic goal of “stimulat[ing] policy responses and enhanc[ing] the capacity of decision makers to act on population health and health system outcomes” (CPHI[a], 2012, p.1). The problem that has been identified by the client is that there are multiple barriers to the use of health equity information and research and there are challenges associated with moving knowledge of health equity into action. These issues are important to CPHI because their work relates to issues within the fields of population health and health equity. A barrier to the use of health equity that was identified by the client related to the capacity of some of their stakeholders to understand complex statistics, specifically the challenges of interpreting the statistical measures that are commonly used to measure health inequalities. These barriers to the use of health equity information and research and others are discussed in depth within the body of the report.
Some of the challenges associated with moving knowledge of health equity into action identified by CPHI relates to the varying needs and preferences of their stakeholders. More and more health regions across Canada are incorporating the objective of improving population health and health equity within their mission, vision and value statements (Neudorf, 2012, p.155; MacNeil, 2012, p.11). This presents a challenge for CPHI since there are varying levels of understanding among the health regions of health equity. Another challenge relates to the fact that CPHI has stakeholders from numerous professions including practitioners, researchers, policy makers, and decision makers. Different groups use different kinds of research and evidence (Bowen & Zwi, 2005, p.601; Grimshaw, 2012, p.3; Armstrong et al., 2007, p.258) and need information communicated in a different ways (Grimshaw, 2012, p.3). This means that different approaches are needed to translate knowledge to different groups.
METHODOLOGY AND METHODS
A needs assessment methodological approach guided this research project. The conceptual model that was used to organize this research project was adapted from an existing needs assessment model and guide that was developed by the United States (US) Office of Migrant Education. The model developed by the US Office of Migrant Education contained three phases: identifying the current state and the desired future state; assessing the difference between the current state and the desired future state (i.e. the gap or the need to be addressed); and finally addressing the need that had been identified. The CPHI branch is seeking to improve the capacity of decision makers to act on population health. Therefore, their desired future state is a health system workforce that is knowledgeable and can act on health equity information. Additional research methods were used to understand the current state and to identify what factors were contributing to the problem identified by the client. A literature review was conducted to assess the current state of the existing health equity related-KT literature. An assessment of existing 2010 CPHI stakeholder interview findings were also used to help understand the current state.
A secondary methodology, an environmental scan, was used to develop a comprehensive
understanding of the current state of health equity-related resources that are available for health system decision makers, policy makers, and policy analysts. Part of the CPHI branch’s role is to support their stakeholders and help them be able to understand and act on population health and health equity. Therefore, it is important for CPHI to be aware of the current state of resources aimed at improving the ability of health system decision makers and policy makers to understand and act on population health and health equity. The methods used to collect data for the scan were: a review of Canadian government and public health organizations websites; a review of international health organization’s websites; and monitoring a health equity-related email list service.
Once the gap between the current and future state was identified, that there is a need to build the capacity of health system decision makers and policy makers to use health equity data or
information, the researcher of this project developed an online course. The course was developed as a first step in addressing the identified needs. Experts in the field of KT and health equity
reviewed the content and their opinions were measured through a closed and open-ended question survey. Then an end-user pilot was conducted and their opinions were collected through a closed and open-ended question survey.
FINDINGS
The findings from the literature revealed that the health equity-related KT literature is limited at this point in time. However, the concepts of KT are starting to expand out of clinical and medical settings into more complex decision making environments, such as public health (Armstrong et al., 2011, p.2). Despite the lack of health equity-related KT literature, there is a small amount of literature relating to KT in public health settings. However, the findings from the literature review revealed that there is very little evidence relating to effectiveness of KT strategies in these settings (Armstrong et al., 2011, p.2; Larocca et al., 2012, p.13; Dagenais et al., 2013, p.6). Lessons from the KT and public health literature are relevant since public health decisions take place in a complex
receive information. A small number of studies and a systematic review, (which included some of the studies), from the KT in public health literature examined strategies to move knowledge into action in a pubic health setting. Some of the main findings were: that standalone passive strategies were ineffective (LaRocca, 2012, p.11; Lavis et al., 2003, p.226); the importance of tailoring
strategies for different end users (LaRocca et al., 2012, p.11); the importance of understanding the context of the end-users (Dobbins et al., 2009, p.12; LaRocca et al., 2012, p. 13 ); and there are no “one-size-fits-all” KT strategies (Mitton et al., 2007, p.756; Contandriopoulos et al., 2010, p.468). However, it is important to note that the transferability of the findings are limited due to the small number of studies and the small sample sizes.
It was identified through the literature review that there are barriers to the use of health equity information (Collins & Hayes, 2007, pp.339-341). These barriers can be broadly categorized as informational, interest-related, ideological and institutional (Collins & Hayes, 2007, pp.339-341). There also appears to be limited instructional resources available for health system decision and policy makers. The findings from the environmental scan revealed that while there are many resources available relating to the social determinants of health, only five readily accessible non-credit courses were identified that related to health equity.
An online course relating to health equity was developed for the client CPHI as a result of the findings from the needs assessment, the environmental scan as well as the literature review, and the assessment of the feedback from existing 2010 CPHI stakeholder interviews. An expert review and end-user pilot test of the course were conducted. The comments from the expert reviewers reinforced findings from the KT literature about the importance of tailoring the content of the information that is being translated and to make sure the information is accessible, actionable, and engaging. Feedback from the end-user pilot survey provided guidance on the usefulness and relevance of the course.
RECOMMENDATIONS
Based on the findings from this report, several recommendations have been presented to CPHI to help improve their future KT activities and achieve their mission. The recommendations are:
Build capacity of decision makers and policy makers across Canada so they can better understand and use health equity and social determinants of health-related concepts, information, and data in their work;
Pursue actively delivered KT strategies rather than passive KT strategies;
Tailor KT strategies for different stakeholders;
Attempt to develop a better understanding of the decision making context and organizational context of end-users;
Continue to evaluate KT activities in order to improve understanding of the effectiveness of KT activities;
Continue to monitor and evaluate the needs of stakeholders in order to keep producing relevant and timely products;
When developing the messaging for products, translate findings to different stakeholder groups in order to increase the reach and accessibility of CPHI products.
Develop resources for stakeholders with differing ability levels; and
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Acknowledgements ... i
Executive Summary ...ii
Table of Contents Table of Contents ... v
List of Figures/Tables ... viii
Abbreviations ... ix
1.0 Introduction ... 1
1.1 Client, Problem definition and Rationale for project ... 1
1.2.1 Client ... 1
1.2.2 Problem Definition and Rationale for Project ... 1
1.2 Project Purpose and Research Questions ... 3
1.2.1 Objective ... 3
1.2.2 Research Question ... 3
1.3. Definitions of Main Terms ... 3
1.4 Organization of Report ... 6
2.0 Background ... 8
2.1 Historical Development of Policy Attention to Health Equity in the International Health Community ... 8
2.2 Policy Action on the Social Determinants of Health and Health Equity within the Canadian Context ... 11
2.3 Role of Health System Decision/Policy Makers in Addressing Health Equity in Canada ... 13
3.0 Conceptual Framework ... 15
3.1 Needs Assessment Model ... 15
3.2 Knowledge-to-Action ... 18
4.0 Methodology and Methods ... 21
4.1 Needs Assessment ... 21
4.3 Environmental Scan ... 24
4.4 Analysis of Findings from 2010 CPHI Interviews ... 24
4.5 Development of Education Course ... 25
4.6 Selection Process – Expert Reviewers ... 25
4.7 Selection Process – End-Users ... 27
4.8 Survey Methods for Expert Review and End-User Pilot ... 28
4.9 Limitations/Delimitations ... 28
5.0 Literature Review ... 30
5.1 The Evolution of the Field of Knowledge Translation ... 31
5.2 Effectiveness of Knowledge Translation Strategies to move Knowledge on the Social Determinants of Health and Health Equity to Health System Decision Makers, Policy Makers, and Policy Analysts ... 32
5.3 Available Literature on Knowledge Translation and Health Equity ... 39
5.4 Barriers to the Implementation of the Social Determinants of Health and Health Equity Agenda . 42 5.5 Summary ... 45
6.0 Addressing the Identified Need ... 46
6.1 Decision to Develop an Online Education Course... 46
6.2 Content Development for the Online Education Course ... 46
7.0 Findings: Environmental Scan, Expert Panel, and Survey ... 48
7.1 Findings from the Environmental Scan ... 48
7.2 Summary of Findings from the Expert Reviewers ... 50
7.3 Summary of Findings from the End-User Pilot Survey ... 53
8.0 Discussion ... 55
8.1 Moving Forward with Knowledge Translation ... 55
8.2 The Importance of the End-User... 56
8.3 Summary ... 58
9.0 Recommendations ... 60
9.1 Build Capacity of Stakeholders... 60
9.2. Knowledge Translation Strategies ... 60
9.3 Tailor Resources for Different Stakeholder Groups ... 61
10.0 Conclusion ... 63
References ... 64
Appendices ... 73
Appendix A – Feedback from 2010 Canadian Population Health Initiative Stakeholder Interviews ... 73
Appendix B – The Canadian Population Health Initiative’s Knowledge Translation Activities ... 75
Appendix C –Survey for Expert Reviewers ... 77
Appendix D –Survey for End-User Pilot Participants ... 80
Appendix E – Ethics Certificate of Approval and Request for Annual Renewal from the University of Victoria Human Research Ethics Board ... 85
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Figure 1. Needs Assessment Phases. Adapted from the US Office of Migrant Education’s
Comprehensive Needs Assessment Guide, 2001……….16 Figure 2. Needs Assessment Model………..18 Figure 3. The Knowledge-to-Action Process………20 Figure 4. Image from the CPHI Online Education Course entitled Equity Action: Health Equity Tools
for Health System Managers ……….48
Table 1. Health Equity-Related Online Resources for Health System Decision and Policy Maker…….50 Table 2. Canadian Population Health Initiative Knowledge Translation Activities………76-77
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BBREVIATIONS
CIHI Canadian Institute for Health Information CIHR Canadian Institute for Health Research CPHA Canadian Public Health Association CPHI Canadian Population Health Initiative CRM Client Relations Management
FPT-ACPH Federal Provincial Territorial Commission on Population Health IMI International Monetary Institution
IMF International Monetary Fund KTA Knowledge-to-Action
KT Knowledge Translation
LHIN Local Health Integration Network MCHP Manitoba Centre for Health Policy MDG Millennium Development Goals
NCCDH National Collaborating Centre for Determinants of Health NCCMT National Collaborating Centre for Methods and Tools PAHO Pan-American Health Organization
PHAC Public Health Agency of Canada RHA Regional Health Authority
UK United Kingdom
UN United Nations US United States
USSR Union of Soviet Socialist Republics
UVIC HREB University of Victoria Human Research Ethics Board
1.0
I
NTRODUCTION
Knowledge translation (KT), the process of moving research or information to relevant health system end-users, is a growing field. While KT originated in clinical settings and was aimed at
getting information to clinicians and medical professionals (Murphy, Fafard, O’Campo, 2012, p.876), KT has since begun to expand to complex decision making environments such as public health (Armstrong et al., 2011, p.2). The end-users in these complex environments, such as Canadian health system decision and policy makers, are often confronted with many different kinds of research and information. Therefore, it is increasingly important for researchers, research organizations or other groups producing information to understand how to effectively move knowledge and research being produced into action.
1.1 CLIENT, PROBLEM DEFINITION AND RATIONALE FOR PROJECT
1.2.1CLIENT
The Canadian Population Health Initiative (CPHI) is the client for this project and is part of the Canadian Institute for Health Information (CIHI) organization. The organization is a not for profit, private organization funded by the Canadian government and the provinces and territories. The mandate of CIHI is “to lead the development and maintenance of comprehensive and integrated health information that enables sound policy and effective health system management that
improve health and health care” (CIHI[c], 2014, para.3). The organization is divided into a number of branches, each with a specific area of focus, such as data or research and analysis. For example, some branches maintain databases and others support health system workers to use CIHI data through research and analysis. The work and products produced by CPHI cover a range of topics such as population health and health system efficiency.
Within the larger organization, CPHI’s mission is to “support Canadian policy makers and health system managers in their efforts to improve population health and reduce health inequalities through research and analysis, evidence synthesis and performance measurement” (CPHI [a], 2012, p.1). The CPHI branch has two specific strategic directions that are designed to enhance decision makers’ and policy makers’ knowledge surrounding population health and health inequalities; and improve their capacity to use said information in their health system decision making. Please refer to Section 1.3 Definitions of Main Terms for complete definitions of the term health inequalities, health inequity and health equity. The first strategic direction is: “build knowledge and
understanding of factors that influence population health, health system outcomes and health inequalities” (CPHI[a], 2012, p.1). The second strategic direction is “stimulate policy responses and enhance the capacity of decision-makers and health system managers to act on population health and health system outcomes” (CPHI[a], 2012, p.1). Therefore, it is essential that CPHI be able to effectively translate the research and knowledge that it produces so that they can achieve their strategic directions and support health system decision makers and policy makers.
1.2.2PROBLEM DEFINITION AND RATIONALE FOR PROJECT
The problem that has been identified by the client is that there are barriers to the use of health equity-related information and research and there are challenges associated with moving
knowledge on health equity into action. This issue is of particular interest to CPHI because one of the primary areas of focus for the branch relates to health inequalities (CPHI[a], 2012, p.1) and the
factors that influence these health inequalities. In order for CPHI to effectively continue to move knowledge into action, it will be important for the branch to develop a more detailed understanding of the barriers to the use of health equity information and the challenges that are associated with moving knowledge into action. It is important to note that different jurisdictions use different terms to capture the concept of differences in health. The main terms used are: health disparities, health inequalities, or health inequities. For complete definitions of these terms please refer to section 1.3 Definitions of Main Terms.
Barriers to the use of health equity information and research were identified by CPHI. The work developed by CPHI sometimes contains complex statistical measures. The statistical measures used to identify health inequalities are complicated and not intuitive for some people. A barrier to the use of their research and health equity information is the capacity, or lack of capacity, of some of their stakeholders to understand complex statistics, more specifically the challenges of interpreting the statistical measures that are commonly used to measure health inequalities. The CPHI branch identified this barrier through findings from their 2010 CPHI stakeholder interviews. The findings from the 2010 CPHI stakeholder interviews can be found in Appendix A.
The client, CPHI, also identified challenges associated with moving knowledge on health equity into action. These challenges relate to the varying knowledge needs and preferences of their
stakeholders. The CPHI branch identified the challenge through: a research project conducted by a University of Victoria graduate student entitled Exploring action on the social determinants of
health in Canada’s health regions (MacNeil, 2012), and through current population health and social
determinants of health research conducted by leading scholars and organizations in these fields. An increasing number of health regions have committed to addressing the social determinants of health and reducing inequalities or inequities in health (Neudorf, 2012, p.155; Kouri, 2013, p.15; MacNeil, 2012, p.11). A growing number of health regions are including the objective of improving population health and health equity within their mission, vision and value statements (Neudorf, 2012, p.155; MacNeil, 2012, p.11). Despite the fact that health inequities are being addressed in numerous health regions across Canada, the action on reducing health inequities is not happening evenly across Canada (Kouri, 2013, p.16). Therefore, some health regions have a comprehensive understanding of health equity concepts and other health regions have a limited understanding. The challenge for CPHI is determining how to effectively communicate their research to health regions with differing levels of knowledge on health equity. The CPHI branch also has a diverse group of stakeholders. These stakeholders range from practitioners to researchers, and also include policy makers and decision makers. Another challenge for CPHI is determining how to continue to effectively communicate information to these different groups.
The knowledge exchange and transfer team of CPHI, the part of CPHI that executes CPHI’s KT activities, would like to continue to strengthen their KT activities by: continuing to improve their KT activities; and by developing products that are designed to help health system managers, policy makers and analysts consider health equity in the decision making process. A list of CPHI’s current KT activities is outlined in detail in Appendix B. As noted above, one of CPHI’s primary areas of focus is on health inequalities (CPHI[a], 2012, p.1) and so the branch is interested in knowing if effective
provincial and regional levels to consider health equity when making program and policy design decisions. This is important for several reasons. Health inequalities have multiple negative impacts on Canadian society because they reduce both the quality of life and life expectancy of thousands of Canadians each year (Butler-Jones, 2008, p.37; McIntosh et al., 2009, p.58; CIHI [b]. 2008, pp.16-17). Therefore, it is important that health system decision makers, policy makers, and policy analysts understand how to use information relating to health inequalities and to consider population health and health equity in their decision or policy making since it has the potential to help improve the quality of health of Canadians.
1.2 PROJECT PURPOSE AND RESEARCH QUESTIONS
1.2.1OBJECTIVE
The objective of this research is to identify if there are effective approaches to moving knowledge on health equity into action for health system decision makers, policy makers, and policy analysts. This is important for CPHI because the research they produce relates to topics surrounding
population health and health inequalities (CPHI[a], 2012, p.1). 1.2.2RESEARCH QUESTION
The purpose of the project is to identify effective approaches of moving knowledge on health equity into action in order for CPHI to strengthen their KT activities and to achieve their strategic goals of improving the ability of health system policy makers, decision makers, and policy analysts at the provincial and regional levels to consider health equity when making program and policy design decisions.
The primary research question for the project is:
What is an effective approach to translate knowledge on health equity to health system policy makers, decision makers, and policy analysts to help them incorporate evidence on health equity into their planning and decision-making?
Secondary research questions that support answering the main research question are:
What does the KT evidence tell us about the best ways to deliver information on health equity to health system policy makers, policy analysts and decision makers?
What tools are available for health system policy makers, analysts and decision makers to incorporate health equity into decision making?
How can the concept of health equity be translated into action?
1.3. DEFINITIONS OF MAIN TERMS
The purpose of this section is to provide detailed definitions for words and concepts from the field of KT that are used throughout the report.
KNOWLEDGE TRANSLATION
The term KT is a term that is used to describe the movement of knowledge to different knowledge users, so that said knowledge can be used by the end-users. The term encapsulates a number of
concepts, specifically the various actions that are involved in the process of taking knowledge, whether it is research or other information and communicating it to the desired stakeholders. One of the most well accepted definitions of KT is “… [KT is] a dynamic and iterative process that includes synthesis, dissemination, exchange and ethically-sound application of knowledge to improve the health of Canadians, provide more effective health services and products and strengthen the health care system”(CIHR [a], 2013, para.1). To summarize, KT is the process of taking research or other forms of knowledge, finding where it fits within the existing knowledge domain and converting it into a format that can be used by health system policy makers, decision makers, clinicians, practitioners, and managers etc. It is meant to facilitate the use of evidence and different types of knowledge in various health system contexts (policy making, clinical settings etc.).
CATEGORIES OF KNOWLEDGE TRANSLATION
There are two overarching categories of KT, integrated KT and end-of-grant KT. A KT strategy, defined in a subsequent paragraph, that has stakeholder engagement throughout the process is often referred to as integrated KT (CIHR [a], 2013). Engaging end-users in the KT process sometimes takes place throughout the entire knowledge-to-action (KTA) process, meaning that end-users are engaged in the KT strategy while the research or knowledge is being developed (CIHR [a], 2013). Alternatively, sometimes interaction with stakeholderst takes place at the end of the research process. This is often referred to as end-of grant KT (CIHR [a], 2013). Knowing the difference between these two approaches is useful since it may help to explain why some studies engage stakeholders throughout the process and why others do not. The level of interaction between the knowledge user and the researcher or knowledge provider will vary depending on many variables including: “...[the] nature of the research findings as well as the needs of the particular knowledge user”(CIHR [a], 2013, para.1).
KNOWLEDGE TRANSLATION STRATEGIES AND ACTIVITIES
A KT strategy is an approach used to support the movement of knowledge into action. Each KT strategy can have different objectives; some aim to improve decision maker’s capacity to use information while others aim to move research to the relevant decision makers (Lavis, 2006, pp.40-41). As such, different types of KT strategies exist and have been categorized based on their general objective. A prominent scholar in the field of KT, Professor JN Lavis, developed three categories to simplify the classification of the different types of KT strategies: knowledge exchange strategies, push strategies and pull strategies (Lavis, 2006, pp. 40-41). Knowledge exchange driven strategies tend to involve researchers (or knowledge producers) and users to work together throughout the process to develop knowledge that meets the needs of both groups (Lavis, 2006, p.41). Push efforts tend to be driven by researchers or knowledge producers. These KT strategies tend to focus on increasing the uptake of research by decision or policy makers (Lavis, 2006, p.40). This type of KT strategy is sometimes referred to as researcher-focused interventions (Armstrong et al., 2013, p. 2). Pull efforts can be broken down into two categories “user pull” led by researchers and “user pull” led by decision or policy makers (Lavis, 2006, p.40). The “user pull” strategies led by researchers aim to improve end-users capacity to apply, use or simply better understand evidence and research (Lavis, 2006, p.40). Whereas end-user led “user-pull” strategies tend to be focused on end-users modifying their own institutional or decision making structures to facilitate the use of research and
A KT strategy can be: active, passive, have multiple components or simply one component. Types of KT activities sometimes referred to as interventions (LaRocca et al., 2012, p.3) can include, but are not limited to: workshops, knowledge brokers, tailored messaging, educational sessions, online resources, access to databases, and decision aids.
TYPES OF KNOWLEDGE USE BY DECISION MAKERS AND POLICY MAKERS
Categories have been developed to describe the different ways that decision makers and policy makers use knowledge. Knowledge can be applied directly, can be used to sway the opinions of others or can alter someone’s worldview about a certain issue. One of the aims of KT is to transfer knowledge to health system decision makers, policy makers, and policy analysts in order to alter their behaviour. Therefore it is important for those transferring knowledge to understand the differences between how individuals use knowledge so they may gain insight into how KT
influenced or altered the knowledge use of the stakeholders. The different types of knowledge use have been categorized as follows: instrumental, symbolic, and conceptual (Innvaer et al., 2002, p. 242). The instrumental use of knowledge simply refers to the direct application of knowledge (Innvaer et al., 2002, p. 242). The symbolic use of evidence refers to when knowledge is used strategically or to achieve a particular aim (Innvaer et al., 2002, p. 242). Finally, the conceptual use of knowledge refers to when knowledge alters an individual’s way of thinking or how they perceive an issue or topic (Innvaer et al., 2002, p. 242). Changes in conceptual and symbolic use of
knowledge are more difficult to measure and identify than the instrumental use of knowledge.
EVIDENCE-INFORMED DECISION/POLICY MAKING
Policy development is a complex process. Policy makers are confronted with competing interests and must weigh and consider multiple types of information. According to Bowen and Zwi,
evidence-based refers to the use of a particular type of evidence, research evidence (Bowen & Zwi, 2005, p.601). Evidence-informed (or influenced) policy making is different. It covers a wider
spectrum of evidence and information “…from a variety of sources, reflective of, and responsive to, the policy and practice context” (Bowen & Zwi, 2005, p. 601). In the context of this research paper, the latter definition is more appropriate since the CPHI stakeholders that this project will be targeting are health system policy makers, analysts, and decision makers at the health region level or provincial level.
INEQUALITIES IN HEALTH
Inequalities in health describe the differences in levels of health that can be seen across population groups (World Health Organization [a], 2014, para.3). The term inequalities in health can be
interpreted in different ways and takes on different meanings in different jurisdictions. Three major understandings of the term have emerged: “health differences between individuals, health
differences between population groups, [and] health differences between groups occupying unequal positions in society” (Graham, 2007, p. 4). The third definition is the term used most commonly internationally, especially European countries and is sometimes used interchangeably with the term inequity in health (Whitehead and Dahlgren, 2006, p.4). Inequalities in health can stem from a variety of interacting structural and intermediary determinants of health.
INEQUITY IN HEALTH
Inequity implies unfairness; therefore, inequity in health represents those inequalities that can be considered to be unfair. According to two of the leading experts in the field, inequities in health are
defined by three major characteristics “they are systematic, socially produced (and therefore modifiable) and unfair” (Whitehead & Dahlgren, 2006, p.2). Although the terms inequalities in health and inequities in health seem similar and are sometimes used interchangeably it is important to be able to distinguish one term from the other. Identifying health inequities involves making normative judgments based on societal perceptions of injustice (NCCDH, 2010, p.7; Whitehead & Dahlgren, 2006, p.3) and “…the meaning attributed by different people to the idea of unfair” (Whitehead & Dahlgren, 2006, p.3).
Please note that the client, CPHI, prefers the use of the term health inequalities. Therefore, throughout the report the researcher applied this term when referring to differences in health. Certain authors or reports that were cited in this report used the term health inequities or inequity in health. The researcher left the term health inequities or inequity in health when the original author used it in order to not alter the meaning of the term used by the cited authors.
HEALTH EQUITY
Health equity represents the absence of those unfair inequalities. Achieving health equity means that “…ideally everyone could attain their full health potential and that no one should be
disadvantaged from achieving this potential because of their social position or other socially determined circumstances” (Whitehead & Dahlgren, 2006, p.4).
HEALTH EQUITY AGENDA
A health equity agenda refers to when an organization, institution, group or political party etc. actions’ or policies’ are motivated by the concept of working towards health equity and reducing health inequalities or health inequities.
1.4 ORGANIZATION OF REPORT
This section provides an overview of the organization of the report.
Background
This chapter is meant to provide readers with a better understanding of the concept of health equity and the importance of moving knowledge into action on the social determinants of health and health equity to health system decision makers, policy makers, and policy analysts. The purpose of this chapter is to provide a comprehensive understanding of the rationale for the pursuit of this research and the importance of this research.
Conceptual Framework
This chapter explains the needs assessment conceptual framework that was used to guide and organize this project. The concept of KTA is also explained in this chapter, in order to further the readers’ understanding of how KT processes are implemented in an organizational setting. The KTA framework described in this analysis was originally developed by Graham et al. (2006) and was then adapted by the Canadian Institute for Health Research (CIHR); it is the framework that CIHR
Methodology and Methods
The methodology and methods chapter provides an overview of the approach used to guide the research as well as the methods used to collect the data. The chapter contains descriptions of: the needs assessment methodology; how the literature review was designed and conducted; the decision to use an environmental scan as well as the methods used to collect data for the scan; the steps taken in the design of the online course; a description of the ethical review approval obtained; description of the selection process for the expert reviewers and the end-users for the pilot; a discussion of the survey methods used to collect data from the expert reviewers and the end-users for the pilot; and finally the limitations and delimitations of this research.
Literature Review
This chapter provides an overview of the health equity-related KT literature. The chapter is divided into four sections based on the main themes that emerged from the literature review. The four main themes are: the evolution of the field of KT; what is known about effective approaches to translate knowledge on health equity to health system decision makers, policy makers, and policy analysts; the available literature on KT and health equity; and finally, the barriers that exist to translating knowledge and information on health equity.
Findings
This chapter outlines the findings from the environmental scan, the expert review and the end-user pilot.
Addressing the Identified Need
Following the identification of the current state and the future state, the next step in the needs assessment process involved identifying an appropriate approach to address the issue. This chapter outlines the decision to develop an online course as well as a brief description of the content of the online course that was developed for CPHI.
Discussion
This chapter provides a discussion of the implications of the research findings for CPHI.
Recommendations
This chapter provides CPHI with recommendations based on the findings from this research. The recommendations are meant to help CPHI strengthen their KT activities and achieve their strategic direction of making decision makers, and policy makers better able to use and apply health equity and population health-related information in decision-making.
Conclusion
This chapter concludes the project by discussing how the client, CPHI, could strengthen their KT activities and achieve their strategic direction based on the findings from this project.
2.0
B
ACKGROUND
The purpose of this chapter is to further explain the rationale for this research and emphasize the importance of pursuing the research. This chapter provides a brief introduction to the historical development of policy attention to health equity both in the international health community but also in the Canadian context. It is meant to provide readers with an understanding of the
importance of the concept of health equity and the evolution of the concept in the global and Canadian health communities.
This chapter also contains information regarding the role of health system decision makers and policy makers in addressing health equity in Canada. The content of this section of the chapter is meant to provide an understanding of why there is a need to effectively communicate knowledge on health equity to health system decision makers, policy makers, and policy analysts.
2.1 HISTORICAL DEVELOPMENT OF POLICY ATTENTION TO HEALTH EQUITY IN THE
INTERNATIONAL HEALTH COMMUNITY
The conception of health as a state of overall wellness has been present within the international health community since the late 1940s. In one of the first public statements about health and wellness, in 1948 the World Health Organization (WHO), a specialized agency of the United Nations (UN) which is an international governmental organization, defined health as “…a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity”
(Preamble to the Constitution of the World Health Organization, 1948, para.1). Societal factors have long been recognized as a major component of what influences an individual’s health. Despite the WHO and the international health communities’ awareness of the multifaceted and sometimes social nature of influences on health, global economic and political forces have often overwhelmed policy action on the social determinants of health and health equity.
Global political and economic forces influenced the direction of the international health agenda following the end of World War II (WWII). From the 1950s through the 1970s, the global climate “…of Cold War politics and decolonization” had a strong influence on the health strategies in the developing and developed world (Irwin & Scali, 2010, p.5). In the wake of WWII, the United States (US) and the Union of Soviet Socialist Republics (USSR) emerged as super-powers on the
international stage. The US promoted capitalism whereas the USSR supported a communist worldview. Political and ideological tensions proliferated and the Cold War began as both super-powers started posturing to gain dominance internationally. The USSR removed themselves from the UN and all UN associated agencies in 1949 (Irwin & Scali, 2010, p. 6). As a result “… UN agencies, including the WHO, came more strongly under the influence of the United States [US] … [and] US officials were at that time reluctant to emphasize a social model of health…” (Irwin & Scali, 2010, p.6). Simultaneously decolonization from European powers was taking place in numerous countries across Africa and Asia. In many instances the health care systems of newly independent countries would reflect “… the [acute care and technology focused] models that had existed under colonial rule” (Irwin & Scali, 2010, p.6). However, reports on concepts such as population health, health
In Canada in the 1970s, a better understanding of the relationship between societal and
environmental influences and their impact on health began to emerge. A seminal document relating to health and the factors influencing health was released in Canada in 1974 entitled A New
Perspective on the Health of Canadians otherwise known as the Lalonde report. The report
challenged traditional views wherein health care services by physicians and hospital care were viewed as the most important way to improve health (Lalonde, 1974, p.18). Instead the analysis indicated that “… there is little doubt that future improvements in the level of health of Canadians lie mainly in improving the environment, moderating self-imposed risks and adding to our
knowledge of human biology” (Lalonde, 1974, p.18). One of the main messages from the report was the importance of pursuing an illness prevention and health promotion approach to health
alongside an acute care approach (Lalonde, 1974, p. 37).
Similar ideas as those expressed in the Lalonde report began to be re-emphasized at the international level during the same time period. In 1978 the WHO released the Alma Ata
Declaration. The main message of the declaration was that how health is addressed needed to shift to include a focus on primary health care as well as acute care (World Health Organization
[WHO][b], 1978, pp.1-3). The Declaration is a seminal document for another reason; it was one of the first major international documents addressing unfair differences in health (WHO [b], 1978, p.1). The messages found in the WHO Alma-Ata Declaration and the Lalonde reports were echoed in the Ottawa Charter for Health Promotion, an international agreement that was signed by various WHO member states at the first International Conference on Health Promotion in 1986. The Ottawa Charter emphasized the importance of: health promotion, healthy public policy, intersectoral action, health as overall wellbeing, health equity, sustainable environments, and community involvement in health care decisions (World Health Organization [WHO], Health Canada [HC] & Public Health Agency of Canada [PHAC], 1986, pp.1-4).
The concepts surrounding prevention and health promotion continued to be discussed in Canada. In 1986, the Department of Health and Welfare of Canada (HWC) released a report entitled Achieving
Health for All: A Framework for Health Promotion referred to as the Epp report. The Epp report
supported a shift toward health promotion as a means to achieve positive health outcomes for all Canadian citizens (Health and Welfare Canada [HWC], 1986, para. 30). The ideas promoted in the report related to the concept of health as a right and that individuals needed to have access to the proper resources to be able to live healthy lives (HWC, 1986, para. 5). The content of the report helped to demonstrate: the existence of inequalities between different groups in Canada; that preventable illnesses were still affecting a large segment of the population; and that community and grassroots level health care was inadequate (HWC, 1986, para. 11-27).
Despite the increased awareness of the social determinants of health and health inequalities at the international health level, the political climate of the 1980s and 1990s stalled action on these issues. The international debt crisis of the 1980s, the dominance of the neoliberal political doctrine in the developed world and the influence of International Financial Institutions (IFI) played a strong role in shaping health strategies of countries around the globe (Irwin & Scali, 2010, p.14, p.15). The central tenants of the neoliberal model of politics and economics was the concept of free markets, more specifically minimal government involvement in both the economy, and social institutions (Irwin & Scali, 2010, p.14). Established following WWII, IFIs such as the World Bank (WB) and the International Monetary Fund (IMF) were created as a means to help regulate the global economy
and provide monetary support to member states. The WB provides loans to nations that are in need of financial support. In the 1980s and 1990s the WB had more resources than the WHO and had also developed a health policy model (Irwin & Scali, 2010, p.17). As a result of these factors “…de facto leadership in global health seemed to shift from the WHO to the World Bank” (Irwin & Scali, 2010, p.17). One of the IMFs roles was to help countries with balance-of-payments (Barnett & Finnemore, 2004, p.48). The decision-making structure of the IMF was (and still is) based on a quota system, whereby a member countries voting power is related to it’s proportion of quota of funds (Kennedy, 2006, p.116). The quota of funds from member states is the main source of funding for the IMF and a member state’s quota is based on their “…relative position in the world economy” (International Monetary Fund, 2014). For a number of years, a small number of member states “…the United States [US], Japan, Germany, France and the United Kingdom [UK]…” maintained a large portion of the voting power and control of decisions that are made at the IMF (Barnett & Finnemore, 2004, p.49).
During the 1980s the US, Germany, and the UK were promoting neoliberal ideologies (Irwin & Scali, 2010, p.15). As noted above, neoliberalism centred on concepts surrounding economic
liberalization such as free markets, privatization, and deregulation (Irwin & Scali, 2010, p.14; King & Wood, 1999, p.371). In order to qualify for loans from the IFIs, developing nations had to make reforms (Kennedy, 2006, p.134) and give up some of their decision-making authority to these institutions. As a result, it has been suggested that components of neoliberalism were “imposed” on developing countries through mechanisms such as “health sector reforms” and “structural
adjustment programmes” that were implemented through IFIs (Irwin & Scali, 2010, pp.15). This resulted in cuts to government expenditures and decreased investment in social and health programs (Irwin & Scali, 2010, pp.15-16). However, major players in the international community such as the UN and the WHO continued to conduct research on issues relating to the social determinants of health and health inequalities.
During the 1990s and early 2000s the WHO and the UN released seminal works on topics such as the social determinants of health, health equity and development issues. Some of the work that emerged at that time included: a Task Force on Health Development from 1994-1997 and the
Health for All in the 21st Century strategy (Irwin & Scali, 2010, p.18). The international community
strengthened plans to improve the global development agenda in the year 2000 with the creation of the UN Millennium Development Goals (MDG). The UN’s MDGs were a global commitment to decrease poverty, increase development efforts and improve the lives of the world’s most
impoverished populations by the year 2015 (United Nations Millennium Declaration, 2000, paras. 11-20). Another important document that emerged during that time was the 2005 Bangkok Charter
for Health Promotion in a Globalized World. The Bangkok Charter reaffirmed the international
community’s commitment to health promotion as had been outlined in previous documents including the 1986 Ottawa Charter (World Health Organization [WHO] [c], 2005, p.1). The concepts of health promotion and addressing the factors that influence health continued to be explored within the international community.
need to be taken to reduce health inequities (WHO CSDH, 2008, p.1). The most recent political commitment towards reducing inequities in health was the 2011 Rio Political Declaration on Social
Determinants of Health (World Health Organization [WHO] [d] 2011). The members of the WHO
committed to working towards reducing health inequities by taking action on the social determinants of health (WHO [d] 2011, p.1, para.1). Despite the vast literature on health promotion, the social determinants of health and health equity, inequalities in health persist in most nations around the globe (Marmot, 2005, p.1099). As discussed, barriers toward
implementing a social determinants of health and health equity agenda stem in part from global socio-economic structures. However, barriers also emerge from structures within nations themselves.
2.2 POLICY ACTION ON THE SOCIAL DETERMINANTS OF HEALTH AND HEALTH EQUITY WITHIN
THE CANADIAN CONTEXTFactors beyond global economic and political forces have limited the adoption of a population health, health promotion, social determinants of health and health equity agenda in Canada. Some of the barriers that have limited the integration of some of these concepts into the health care system in Canada include: the health funding structure, federal and provincial jurisdictional tensions and the structure of the policy system (Collins & Hayes, 2007, pp. 338-339). The barriers that have been identified can be broadly categorized as ideological, institutional, interest-related and
information-related barriers (Collins & Hayes, 2007, pp. 338-339). These barriers will be discussed at length in section 5.4 Barriers to the Implementation of the Social Determinants of Health and Health Equity Agenda. Despite the existence of these barriers, the concepts of population health, the social determinants of health and health equity are beginning to be integrated into the mission, vision, and values of numerous health regions across Canada. (Neudorf, 2012, p.155; MacNeil, 2012, p.11)
Canada has long been recognized as a leader in the fields of population health and health promotion (Neudorf, 2012, p.155; Mikkonen & Raphael, 2010, p.7). However, only in recent decades has there been a shift of focus in the health system towards the concepts of population health, health promotion and illness prevention, alongside an acute care approach (Neudorf, 2012, p.155). The health care system in Canada has been dominated by a focus on crisis management, health services and treatment of illness (Neudorf, 2012, p.155; Frankish et al., 2007, p.1, p.4). Despite awareness of a population health approach to health care, many decision makers have felt “…pressure to focus on clinical care” (Cohen et al., 2014, p.4, p.6). While treatment of illness will continue to be an important component of health care decision-making, a population health approach has the potential to improve the health of different groups but also has the potential to improve the sustainability of the Canadian health system (Neudorf, 2012, p.155). The reduction of health inequalities is a foundational element of a population health approach (Public Health Agency of Canada as cited in Neudorf, 2012, p.155).
The integration of the concepts of population health and health equity into the health system varies by jurisdiction (Neudorf, 2012, p.155; Kouri, 2013, p.15; MacNeil, 2012, p.11). In the Canadian federal system, provinces have jurisdiction over health care. Each province is responsible for managing their respective health care system. Most provinces delegate some of the responsibility
of health care to health regions. These are often referred to as Regional Health Authorities (RHAs) and in Ontario health regions are referred to as Local Health Integration Networks (LHINs). In this report, RHA and LHINS will be referred to as health regions. The provinces of Alberta and Prince Edward Island are not divided into regions (Kouri, 2013, p.1). It should be noted that the boundaries of health regions are subject to change. Health regions operate just below the provincial level and are responsible for making program and planning decisions as well as “administrative policy” decisions (Bowen, Erickson, Martens, Crockett, 2009, p.90). Their structure and levers of power provide them with the ability to act on the social determinants of health (Frankish et al., 2007, p.41). Across most regions (except Ontario) public and population health units are situated within the health region and these branches tend to be the champions for social determinants of health and health equity (Kouri, 2013, p.2).
The recognition of the impact of social determinants of health on health outcomes has increased at the health region level across Canada and several health regions have committed to addressing population health and health equity (Neudorf, 2012, p.155; MacNeil, 2012, p.11). A recent analysis of the vision and mission statements of health regions across Canada found that most of them mentioned population health (Neudorf, 2012, p. 155). However, the same study also noted that despite the prevalence of population health language in mission and value statements that “… [the population health] ideology has not translated into a wholesale system redesign thought necessary for large scale results” (Neudorf, 2012, p.155). Another recent analysis aimed at identifying action on the social determinants of health and health equity in Canada at the regional level found similar results, that health equity was identified as a priority by health regions but specific action on health equity was limited (MacNeil, 2012, p.11). The author made note that the limitation of the research was that the information found from the publicly available sources may not fully reflect the range of equity-related activities that were taking place within health regions at that time (MacNeil, 2012, p.11).
The findings from the two above-mentioned analyses highlight that the concepts of population health and health equity are beginning to be incorporated into the larger strategic plans and programs of some health regions. The Wellesley Institute, a Canadian “…profit and non-partisan research and policy institute…”(Wellesley Institute, 2014), recently released a report entitled Learning From Others, Health Equity Strategies And Initiatives From Canadian Regional
Health Authorities. The 2013 Wellesley Institute report helped to confirm that an increasing number
of regions are taking policy and program action on health disparities (another term used to describe differences in health or health inequalities) (Kouri, 2013, p.13-17). The Wellesley paper scanned the activities of health regions across Canada and the findings showed that although action on health equity is still largely concentrated in public and population health departments, in some cases these concepts are being integrated into the planning of the larger health regions (Kouri, 2013, p.13). The study also confirmed “…work [being done on health inequalities] is uneven across the country” (Kouri, 2013, p.16). Some health regions have taken an active role in addressing health equity whereas others have seemingly not acted on these issues or have taken very little policy or program action, again the author noted that not all health regions make information about their programs publicly available so there may be some programs that were not identified through the scan (Kouri,
2.3 ROLE OF HEALTH SYSTEM DECISION/POLICY MAKERS IN ADDRESSING HEALTH EQUITY IN
CANADA
There is little research available that evaluates the specific role of health system decision makers, policy analysts, and policy makers in addressing health equity. However, it has been widely
recognized that in order for a health equity agenda to flourish, leaders from across both the health and other sectors will need to act as champions (WHO & CSDH, 2008, p.194; Butler-Jones, 2008, p.68). It has been suggested that it will be important to raise awareness of issues relating to the social determinants of health and health equity and communicating it to decision and policy makers (WHO &CSDH, 2008,p.190). However, it will be even more important for health system policy makers, decision makers, and policy analysts to consider health equity when making decisions (WHO & CSDH, 2008, p.190). As highlighted above, health system decision and policy makers have a crucial role to play in moving the health equity agenda forward. In order for them to be aware of these issues and consider these issues in their decision-making it will be important for the
organizations creating and brokering knowledge in this area to be able to effectively communicate their research and knowledge to the relevant decision and policy makers.
At a more general level there have been papers and reports on potential roles of the health care sector in addressing the social determinants of health and health inequalities. There has been some recent work on the role of the health sector with regards to the Canadian context. A Canadian Federal, Provincial and Territorial task group on Health Disparities identified four activities that the health sector could engage in to help reduce health disparities. The recommendations of the task group for the health sector included: an emphasis on intersectoral work; “make health disparities reduction a health sector priority”; “integrate disparities reduction into health programs and services”; and “strengthen knowledge development and exchange activities” (Health Disparities Task Group of the Federal/Provincial/Territorial Advisory Committee on Population Health and Health Security [FPT PHHS], 2004, pp. 7-9). Similar suggestions regarding the potential role of the
health care sector in addressing the social determinants of health have been presented at the international level.
Roles that the health sector might take to reduce health inequalities have also been discussed at the global level. The WHO 2011 report entitled Closing the Gap: Policy into Practice on Social
Determinants of Health discussed the role and some actions that the health sector could take to
advance the global health agenda on health equity (World Health Organization [e], 2011, p.24). The report identified potential roles and actions for the health sector including: taking a leadership role by promoting the importance of a social determinants of health approach; facilitating dialogue with other sectors and levels of government; developing an understanding of the goals and objectives of other sectors to find areas of alignment and help other sectors achieve goals that relate to health; evaluate intersectoral activities and the impacts of policy interventions; “building the knowledge and evidence base of policy options and strategies”; and “ … building capacity through better mechanisms, resources, agency support, and skilled and dedicated staff” (WHO [e], 2011, p.24). Both the 2011 WHO Closing the Gap report and the Canadian task group emphasize the importance of the health sector: taking a leadership role and making health disparities (another term for
differences in health or health inequalities) and health inequities a priority; as well as engaging in intersectoral action and capacity building as a means of addressing inequalities in health.
More recently, the Wellesley Institute developed a health equity roadmap outlining potential actions that could be taken by actors in the health care sector to better integrate health equity into the health care system. The seven actions were as follows (Gardner, 2012, pp.2-4):
Incorporate health equity values into different facets of the health system such as planning and delivery of services;
“[A]ligning equity with system drivers and priorities”;
Search for the most effective ways to reduce health inequities;
Build equity into the performance management and deliverables of health system provider organizations;
Diversify the use of resources to develop programs targeted at populations experiencing high levels of health disparities (inequalities) or to address barriers these populations experience when attempting to access the health care system;
Facilitate the development of “equity focused innovation”; and
Shift focus of health care to a more upstream approach, to encourage a focus on health promotion and address the structural and intermediary determinants of health.
Similar themes as those identified by the 2011 WHO Closing the Gap report and the Canadian task group are echoed the actions that are discussed in the Wellesley Institute equity roadmap.
In the Canadian public health sector and the international health community; the concept of health equity and its impacts on the population are generally well understood. The rising number of health regions in Canada that are taking action on social determinants of health and health inequalities indicates that these concepts have begun to spread and be adopted by health system actors outside of public health. However, if significant action on the social determinants of health and health equity is to take place, these concepts need to be understood by a larger proportion of actors in the health system outside of public health. Key members of the international health community have emphasized the importance of moving knowledge into action and of communicating the
information so that it can be understood (WHO &CSDH, 2008, p.190). Therefore, it will be
important for those producing research on issues relating to the social determinants of health and health equity to effectively communicate to different stakeholders and to understand the barriers confronting the health equity agenda so that health system decision makers and policy makers can become aware of these issues and consider them in their decision and policy making processes.
3.0
C
ONCEPTUAL
F
RAMEWORK
This chapter outlines the conceptual framework used to organize this research and explains the concept of KTA.
3.1 NEEDS ASSESSMENT MODEL
The research for this project was structured as a needs assessment. The needs assessment model that was used to organize this research project was adapted from a needs assessment model and guide that was developed by the US Office of Migrant Education. A needs assessment is structured according to three distinct phases: the identification of the current state; the difference between the desired end state and the current state; and finally identifying what approaches would help to address the gap between the current state and the future state, as outlined in Figure 1 (US
Department of Education, Office of Migrant Education, 2001, p. 8, p.13, p. 17).
Figure 1. Needs Assessment Phases. Adapted from the US Office of Migrant Education’s Comprehensive Needs Assessment Guide, 2001.
The first stage of this analysis involved identifying the problem or the current state. As noted in section 1.2 Project Purpose and Research Question, the purpose of this research project is to identify if there are effective approaches of moving knowledge on health equity into action for health system decision makers, policy makers, and policy analysts. The reason is twofold, to help CPHI strengthen their KT activities; and to achieve their strategic goals of improving the ability of health system policy makers, policy analysts, and decision makers at the provincial and regional levels to consider health equity when making program and policy design decisions. Therefore, the desired state for CPHI is to have a workforce knowledgeable on health equity.
The current state was identified through a literature review, an assessment of existing CPHI 2010 stakeholder interview findings (conducted by CPHI staff members) and through an environmental scan methodology. Through the literature review, it was identified that the literature on health
equity-related KT is limited and that little is known about the effectiveness of health equity-related KT strategies. The literature review also revealed that barriers exist to the pursuit of KT and
separate barriers to working toward a health equity agenda also exist.
The literature review helped to reveal that four major barriers have limited the advancement of a health equity agenda: institutional, ideological, interest-related and informational. These barriers are outlined in detail in section 5.4. Barriers to the Implementation of a Social Determinants of Health and Health Equity Agenda. The institutional, ideological and interest-related barriers will take time and concerted effort to change. The informational barriers to the health equity agenda are more actionable than the others and provide a good stepping-stone for action to move the health equity agenda forward. For example, a barrier to KT and the movement of knowledge into action that was identified through the literature review was the lack of capacity of some decision makers and policy makers to use and understand research in general (Lavis, 2006, p.41; Mitton et al., 2007, p.737). Building capacity to understand and use research and information could lead to evidence-informed decision-making (Bowen et al., 2009, p.96; Orton et al., 2011, p.8, p.9). This is relevant since evidence-informed decision-making has been identified as important for moving the health equity agenda forward (Measurement and Evidence Knowledge Network [MEKN], 2007, p.16). The CIHI organization, and by proxy, CPHI, is mandated to be neutral and as such cannot pursue any political activities or make any recommendations that might be perceived as political in nature. Therefore CPHI can address some of the informational barriers (i.e. these are consistent with CPHI’s mission).
The environmental scan alongside the findings from 2010 CPHI stakeholder interviews helped to highlight how there is a lack of instructional resources for decision makers and policy makers relating to health equity. A summary of the analysis of the findings of the 2010 CPHI stakeholder interviews can be found in Appendix A. The findings from the environmental scan are outlined in detail in section 7.1 Findings from the Environmental Scan. The CPHI end-users that were interviewed included health system decision makers, and policy makers such as: public health practitioners, consultants, coordinators, and policy analysts. The analysis of the findings from the stakeholder interviews revealed that the end-users would like CPHI to develop more tools and products to help them understand population health tools for planning and evaluation, inequalities in health, and population health definitions and statistics. These findings led to the identification of the current state, the desired future state and the need that could be addressed to help reduce the gap between the current state and the future state, which have been outlined in Figure 2.
Figure 2 . Needs Assessment Model.
The next step in the process involved identifying how to address the need. The need that was identified was the need to improve the capacity of health system decision makers, policy makers and, policy analysts to use health equity-related data or information. The decision to address the need to build the capacity of health system decision makers, policy makers, and policy analysts with an online learning course was based on: the environmental scan, the findings from the 2010 CPHI stakeholder interviews, and the literature. As noted above, the environmental scan helped to identify the lack of instructional resources aimed at helping decision makers, policy makers, and analysts relating specifically to health equity, and more specifically health equity-related data. In 2010, CPHI conducted 14 key stakeholder interviews with the aim of improving their
understanding of what CPHI stakeholders needed from CPHI in terms of products or education courses. One of the objectives of the interviews was “to identify specific topics and content options for inclusion in new CPHI education products” (CPHI [b], 2010, p.1). The interviews were not
focused solely on determining health equity-related educational needs but all potential education content. With regards to use of data, literature and indicators, stakeholders identified the following training needs relating to data:
“…learning methods to better understand and use disparities data (to understand how to achieve health equity within their particular health area)… and incorporating external promising practices that might work in users’ respective settings” (CPHI[b], 2010, p.3). Findings from the literature suggest that KT strategies did not have to be complex to be effective and that understanding end-user context and end-user characteristics were important for
successful KT (LaRocca et al., 2012, p. 11). A KT strategy is more likely to be effective if it has been tailored to a specific group (LaRocca et al., 2012, p. 11). Passive, stand-alone KT strategies were
